Chlorhexidine gluconate with cetrimide (e.g., Savlon). AVOID using: Hydrogen
peroxide (0.3%), which is not appropriate for surgical scrub or client prep; ...
From Infection Prevention: A Reference Booklet for Health Care Providers © 2001 EngenderHealth
Aseptic Technique Aseptic technique refers to the practices performed just before or during a clinical or surgical procedure to reduce the client’s risk of infection by reducing the likelihood that microorganisms will enter areas of the body where they can cause infection. Aseptic technique includes: • Using barriers (surgical attire) • Surgical scrub and gloving • Client prep • Establishing and maintaining a sterile field • Using good surgical technique • Creating a safer surgical/procedure area
Barriers: Surgical attire Gloves prevent microorganisms on the provider’s hands from entering the client and protect the provider’s hands from contact with blood, other fluids, or tissues. Masks prevent microorganisms expelled during talking, coughing, or breathing from entering the client and protect the provider’s mouth from splashes of blood or other fluids. Eyecovers and faceshields protect the provider’s eyes, nose, and mouth from splashes of blood or other fluids. Gowns and waterproof aprons prevent microorganisms from the provider’s arms, torso, and clothing from entering the client and protect the provider’s skin and clothes from splashes of blood and other fluids. Caps prevent microorganisms from hair and skin on the provider’s head from entering the client.
Footwear that is clean and sturdy (closed rubber or leather boots or shoes) helps minimize the number of microorganisms brought into the surgical/procedure area and protects the service provider’s feet from injury or splashes of blood and other fluids.
8
Surgical scrub Scrubbing reduces the client’s risk of infection in case surgical gloves develop holes or tears. Warm, moist conditions inside gloves promote the growth of microorganisms. Performing surgical scrub with an antiseptic before gloving removes or kills many microorganisms, and also helps prevent this growth.
Steps of Surgical Scrub
3
4
Remove all jewelry on your hands and wrists.
Clean under each fingernail with a stick or brush. It is important for all surgical staff to keep their fingernails short.
Holding your hands up above the level of your elbow, apply the antiseptic. Using a circular motion, begin at the fingertips of one hand and lather and wash between the fingers, continuing from fingertip to elbow. Repeat this for the second hand and arm. Continue washing in this way for 3–5 minutes.
Adjust the water to a warm temperature and wet your hands and forearms thoroughly.
5
Rinse each arm separately, fingertips first, holding your hands above the level of your elbow.
6
7
Using a sterile towel, dry your hands and arms—from fingertips to elbow—using a different side of the towel on each arm.
9
Keep your hands above the level of your waist and do not touch anything before putting on surgical gloves.
Aseptic Technique
1&2
Recent studies have shown that using a brush during surgical scrub provides no greater reduction of microorganisms on the hands than scrubbing with antiseptic alone. Surgical scrub may be performed using either a soft brush or sponge or using an antiseptic alone. Avoid using a hard brush, which is not necessary and may irritate the skin.
Alternative methods of surgical scrub Although the use of antiseptic for surgical scrub is recommended, an alternative method is necessary when surgical staff members are allergic to the available antiseptic solutions or when antiseptics are not available. Performing surgical scrub with soap and water, followed by an alcohol handrub, can be used in place of antiseptics in these situations. To do this: Step 1 Perform a surgical scrub with plain soap and warm, running water while following the steps demonstrated on page 9.
Step 2 Apply 3–5 mL of alcohol (or—because using alcohol alone can dry the skin—use an alcohol handrub solution made up of 2 mL glycerine, propylene glycol, or sorbitol mixed with 100 mL of 60–90% alcohol).
Step 3 Rub hands together until they are dry.
Ideally, surgical scrub should be performed before every procedure. However, to prevent skin irritation from too-frequent scrubbing in high-volume settings, use 3–5 mL of an alcohol handrub solution between clients, rubbing your hands together until the alcohol dries. Then scrub every hour or after every four clients, whichever comes first. Note that alcohol handrub does not remove soil or organic material such as blood. If gloves are torn or punctured, or if there is blood or other body fluids on your hands after you remove your gloves, a surgical scrub should be performed.
10
Surgical Scrub Tips: ☛ Warm water makes antiseptics work more effectively. Avoid using ☛ ☛
Surgical gloves Wear sterile or high-level disinfected* surgical gloves for any procedure where your hands will come in contact with the client’s bloodstream or tissues under the skin. It is important to put on and remove the gloves correctly. Gloves become contaminated: • If you touch the outside of the glove with your bare hand • If you touch anything that is not sterile or high-level disinfected while wearing the gloves • If you hold your gloved hands below the level of your waist • If either glove develops a hole, tear, or puncture
Putting on surgical gloves Surgical gloves are cuffed to make it easier to put them on without contaminating them. When putting on surgical gloves, remember that the first glove should be picked up by the cuff only. The second glove should then be touched only by the other glove. Remember that the outside of the glove package is not sterile. If you will open the outer package of gloves yourself, do so before you perform a surgical scrub.
* Sterilization and high-level disinfection are discussed in detail in the Instrument Processing chapter (page 25).
11
Aseptic Technique
☛ ☛
hot water, which removes protective oils from the skin. If you routinely perform surgical procedures, you should keep your fingernails short. Always keep your hands above your elbows during and after scrubbing. Avoid using a hard brush during scrubbing. Always use an antiseptic during surgical scrub. If you are allergic to antiseptics or if an antiseptic is not available, scrub your hands with plain soap, dry them, and use an alcohol handrub.
Steps of Putting on Surgical Gloves
1
2
3
Prepare a large, clean, dry area for opening the package of gloves. Either open the outer glove package and then perform a surgical scrub, or perform a surgical scrub and ask someone else to open the package of gloves for you.
Open the inner glove wrapper, exposing the cuffed gloves with the palms up.
Pick up the first glove by the cuff, touching only the inside portion of the cuff (the inside is the side that will be touching your skin when the glove is on).
4
5
While holding the cuff in one hand, slip your other hand into the glove. (Pointing the fingers of the glove toward the floor will keep the fingers open.) Be careful not to touch anything, and hold the gloves above your waist level.
Pick up the second glove by sliding the fingers of the gloved hand under the cuff of the second glove. Be careful not to contaminate the gloved hand with the ungloved hand as the second glove is being put on.
6
Put the second glove on the ungloved hand by maintaining a steady pull through the cuff. Adjust the glove fingers and cuffs until the gloves fit comfortably.
Removing contaminated surgical gloves As you remove the gloves, do not allow the outside surface of the gloves to come in contact with your skin. Avoid letting the gloves snap, as this may cause contaminants to splash into your eyes or mouth or onto your skin or other people in the area. Remove used gloves before touching anything: countertops, faucets, and pens and pencils are frequently contaminated because health care workers touch them while wearing used gloves.
12
Steps of Removing Surgical Gloves
2
3
Rinse gloved hands in a basin of decontamination solution to remove blood or other body fluids.
Grasp one glove near the cuff and pull it partway off. The glove will turn inside out. Keep the first glove partially on before removing the second one to protect you from touching the outside of a glove with your bare hand.
Leaving the first glove over your fingers, grasp the second glove near the cuff and pull it partway off. Keep the second glove partially on.
5
4
Pull off the two gloves at the same time, being careful to touch only the inside surface of the gloves with your bare hand.
If the gloves are disposable or are not intact, dispose of them immediately. If they are to be processed for reuse, decontaminate them before processing. Wash hands immediately after gloves are removed, since tiny holes or tears in gloves may leave you at risk of exposure to contaminated fluids.
Surgical Glove Tips: ☛ The outside of the glove package is not sterile. Either open the outer pack☛ ☛ ☛ ☛
age before surgical scrub, or have another person open it for you. If the gloves become contaminated during a procedure, stop what you are doing, step away from the sterile field, remove the contaminated gloves, and put on new gloves. Don’t let gloves snap while you are removing them or blood and other matter may splash on you or on those around you. During removal, don’t allow the outside surface to contact your skin. Remove your used gloves before touching anything—including countertops, faucets, pens, and pencils.
13
Aseptic Technique
1
Client prep Proper client prep with antiseptics before a clinical or surgical procedure is critical, since bacteria from a client’s skin or mucous membranes can cause infections. Shaving the surgical/procedure site is no longer recommended because it causes small nicks and breaks in the skin where bacteria can grow and multiply, and it can lead to increased risk of postprocedure infections. Hair around the surgical/procedure site may be clipped very short if it interferes with the procedure. If the site must be shaved: 1) use antimicrobial soap and water or shave dry; and 2) shave immediately before the procedure, in the operating theater or procedure room. To properly prep a surgical/procedure site: 1. Wash the area with soap and water. 2. Apply an antiseptic and gently scrub the skin in a circular motion, beginning in the center of the site and moving out, using sterile cotton balls, cotton wool, or gauze sponges held by a sponge forceps. For the vagina, cervix, and other mucous membranes: Do not use alcohol or alcohol-based antiseptics on mucous membranes. Using sterile cotton balls, cotton wool, or gauze sponges held by a sponge forceps, apply an antiseptic liberally to the cervix and vagina before instrumentation of the uterus.
About antiseptics An antiseptic is a chemical agent used to reduce the number of microorganisms on skin and mucous membranes without causing damage or irritation. In addition to removing or killing microorganisms, antiseptics may also prevent the growth and development of some types of microorganisms. Antiseptics are used for: • Skin, cervical, or vaginal preparation before a clinical procedure • Surgical scrub • Handwashing in high-risk situations, such as before an invasive procedure or contact with a client at high risk of infection (e.g., a newborn or immunosuppressed client) Antiseptics are not meant to be used on inanimate objects, such as instruments and surfaces. Antiseptics are designed to be used for reducing or destroying microorganisms on the skin or mucous membranes without damaging these tissues. They usually do not have the same killing power as chemicals used for disinfection of inanimate objects. Never use antiseptic solutions to disinfect inanimate objects, such as instruments and reusable gloves, and never leave items such as pickup forceps, scissors, scalpel blades, and suture needles soaking in an antiseptic solution.
14
Common antiseptics used for client prep: • Iodophors (e.g., Betadine) • 4% chlorhexidine gluconate (e.g., Hibiclens) • 1%–3% iodine, followed by 60%–90% alcohol (ethyl or isopropyl) • Chlorhexidine gluconate with cetrimide (e.g., Savlon)
Preventing contamination of antiseptic solutions Using contaminated solutions can cause infections in clients. Solutions become contaminated when: • The water used to dilute a solution is contaminated • Containers in which the solution is placed are contaminated • Microorganisms from skin or objects contact the solutions during use (such as when removing cotton balls from a solution for use in skin prep) • The area in which solutions are prepared or used is not clean Proper handling will reduce the chances of contaminating antiseptic solutions. Pour solutions into smaller containers for use during service delivery to avoid contaminating the stock container. Pour solutions out of the container without touching the rim or the solution itself with your hands, a cotton swab, cloth, or gauze. These can contaminate the entire container of solution. Store solutions in a cool, dark area, because direct light or excessive heat may reduce their strength, making them more susceptible to contamination.
Client Prep Tips: ☛ Never leave cotton balls, cotton wool, or gauze sponges soaking in an antiseptic. ☛ Never dip cotton or gauze into the antiseptic container. Instead, pour some antiseptic into a small container, dip the cotton or gauze into this small container, and discard the unused antiseptic left over after client prep. ☛ Shaving the surgical site is not recommended, because it causes small nicks or cuts in the skin where bacteria can grow and multiply. Instead, hair may be clipped short.
15
Aseptic Technique
AVOID using: Hydrogen peroxide (0.3%), which is not appropriate for surgical scrub or client prep; products containing quaternary ammonium compounds, such as benzalkonium chloride (e.g., Zephiran), which are disinfectants and should not be used as antiseptics; or compounds containing mercury (such as mercury laurel), which are highly toxic.
Properties of Common Antiseptics Antiseptics vary between countries, and a variety of products are available throughout the world. This section notes the most common antiseptics and provides the trade names of commonly available products. In general, these have been studied extensively and their effectiveness is known. The information here reflects the most up-to-date scientific studies available. If possible, use these antiseptics, since others may not have been properly studied and their effectiveness may not be known. Iodophors, such as povidone iodine (e.g., Betadine), contain iodine in a complex form, making them relatively nonirritating and nontoxic.
• Antimicrobial spectrum: Effective against a range of microorganisms. • Advantages: Less irritating to the skin than iodine; can be used on • •
•
mucous membranes. Disadvantages: Effectiveness is moderately reduced by blood or other organic material. Usage: Recommended for surgical scrub and client prep, and is the best antiseptic for use in the genital area, vagina, and cervix. Effective 1–2 minutes after application; for optimal effectiveness, wait several minutes after application. Use full strength; do not dilute. Comments: Iodophors are distinctly different from iodine. Iodophors are sudsy; iodine is not.
Chlorhexidine gluconate (e.g., Hibitane, Hibiclens, Hibiscrub); Chlorhexidine gluconate with cetrimide (e.g., Savlon)
• Antimicrobial spectrum: Effective against a range of microorganisms, but has a minimal effect on tuberculosis and fungi.
• Advantages: Good, persistent effect; remains effective for at least 6 •
•
hours after being applied. Effectiveness is not reduced by organic material. Disadvantages: On rare occasions, products containing chlorhexidine have been reported to cause irritation, especially when used in the genital area. Effectiveness can be reduced by hard water, hand creams, and natural soaps. Usage: Recommended for surgical scrub and skin prep. Preparations without cetrimide are preferable. While products containing chlorhexidine are ideal for surgical scrub and skin prep, they may cause irritation if used in the genital area, vagina, or cervix. Chlorhexidine is the best alternative if an iodophor is not available.
16
• Comments: The concentration of chlorhexidine in products with the name Savlon may vary from one country to another. Savlon products containing at least 4% chlorhexidine are appropriate for use as antiseptics. Savlon products containing less than 4% chlorhexidine in an alcohol base are also adequate, but should not be used on mucous membranes.
• Disadvantages: Can cause skin irritation. Effectiveness is markedly reduced by blood or other organic material.
• Usage: Too irritating for routine use in surgical scrub or for use on mucous membranes. Because of potential irritation when used for skin prep, iodine must be allowed to dry and then removed from the skin with alcohol. Alcohol (60%–90% ethyl or isopropyl)
• Antimicrobial spectrum: Effective against a range of microorganisms. • Advantages: Kills microorganisms rapidly. Most effective in reducing • • •
microorganisms. Effectiveness is moderately reduced by organic material. Disadvantages: Has a drying effect on skin. Cannot be used on mucous membranes. Usage: Cannot be used when skin is dirty; wash the area before applying. It must dry completely to be effective. Comments: 60–70% strength is most effective because alcohol must be diluted for optimal effectiveness, and it is also less drying to skin.
Para-chloro-meta-xylenol, PCMX, chloroxylenol (all three also known as Dettol) • Antimicrobial spectrum: Fairly effective against most microorganisms. • Advantages: Has a persistent effect over several hours. Activity is only minimally reduced by blood or other organic material. • Disadvantages: Less effective than chlorhexidine and iodophors. • Comments: Not recommended for routine use. Antiseptic PCMX preparations containing alcohol should not be used on mucous membranes. Disinfectant preparations should not be used as antiseptics.
17
Aseptic Technique
Iodine; tincture of iodine (iodine and alcohol) • Antimicrobial spectrum: Effective against a range of microorganisms. • Advantages: Fast acting.
Establishing and maintaining a sterile field A sterile field is created by placing sterile towels or surgical drapes around the surgical/ procedure site. A sterile field should also be established on the stand that will hold sterile instruments and other items needed during the procedure.
Sterile
Sterile
Items below the level of the draped client are outside the field and Nonsterile are not sterile. A gowned and gloved provider’s sterile area extends from the chest to the level of the sterile field. Sleeves are sterile from 5 cm above the elbow to the cuff. To maintain a sterile field:
• Allow only sterile items and personnel within the sterile field. • Do not contaminate items when opening, dispensing, or transferring them.
• Consider any sterile item that has been penetrated (cut, wet, or torn) to be nonsterile.
• Never set up a sterile field near a door or an open window. • When in doubt about whether or not an item is still sterile, consider it to be contaminated.
Good surgical technique Meticulous attention to bleeding and gentle tissue handling during surgical and clinical procedures can help reduce the risk of infection. Postprocedure infections are more likely to occur in tissue that has been damaged due to rough or excessive manipulation during surgery or when there is excessive bleeding (because the tissue is then more susceptible to invasion by microorganisms).
18
Use of prophylactic antibiotics The use of prophylactic antibiotics (giving antibiotics before a procedure to prevent infections from developing) does not take the place of good infection prevention. In general, prophylactic antibiotics may be indicated in contaminated or clean-contaminated surgical procedures, in those involving implantation of a foreign body, or when the client is severely immunosuppressed.
Avoid routine use of prophylactic antibiotics: it increases costs and increases the likelihood of promoting antibiotic resistance.
Creating a safer surgical/procedure area Specific rooms should be designated for performing surgical/clinical procedures. Limiting the traffic, activities, and the number and movement of people in these areas will lower the risk of infection, since the number of people and amount of activity influence the number of potentially disease-causing microorganisms. To maintain a safer environment: • Reduce the number of people permitted in the area. (It is important to restrict the number of people to only those involved in the activities being carried out.) • Define the movement of people and activities within the area. • Close doors and curtains during all procedures. • Require that personnel in surgical areas wear clean clothes, a mask, a cap, and sturdy footwear. • Enclose these areas to minimize dust and eliminate insects. • Air-condition the areas, if possible. • Disinfect and clean examination/operating tables, counters, instrument carts or trolleys, light handles, and any other surfaces that may have been contaminated with blood or other body fluids during a procedure before a new client is brought into the room.
19
Aseptic Technique
Prophylactic antibiotics are often prescribed inappropriately (e.g., when they are not effective against microorganisms likely to cause infections) or given at the wrong time in relation to the procedure (e.g., when given postoperatively instead of pre- or intraoperatively), thus decreasing the likelihood that they will have any effect.
